Rethinking Breast Cancer Treatment
It’s October again and we are being bombarded with a great deal of hype about the risks and dangers of getting breast cancer. After the New Zealand Herald featured an article about a 23-year-old woman who was diagnosed with DCIS (ductal carcinoma in situ) and had a mastectomy, it was refreshing to see the 12 October issue of TIME magazine feature an article on why doctors are rethinking breast cancer treatment. The article addresses the thorny issue of the overdiagnosis and overtreatment of DCIS and how women are being subjected to “too much chemo, too much radiation, and way too many mastectomies.”1
DCIS is now usually referred to as early stage breast cancer when it is not, as it is non-invasive, found only inside the milk ducts and not in the surrounding breast tissue. In his book Mammography Screening: truth, lies and controversy, Peter Gøtzsche writes:
“Much of what we call breast cancer is not even a disease, but cell changes that women do not benefit from having detected and treated.”2
DCIS once accounted for about 3% of breast cancers detected as a result of breast cancer screening but now accounts for around one in four so-called breast cancers.
“Now those at the vanguard of breast cancer treatment are calling for a major shift in the way doctors treat – and talk about – the disease, from the first few millimetres of suspicious-looking cells in milk ducts to the invasive masses found outside of them. That’s making the tough conversations between a woman and her cancer doctor even harder, but it also stands to make them more fruitful.
Because as good as we have gotten at finding breast cancer – and we have gotten very good – all this new data suggests there may be better ways to treat some breast cancers, particularly those at the early stage. Evidence is mounting that aggressive treatments, designed in earnest to save women’s lives, can have unforeseen and sometimes devastating consequences.
Call it collateral damage. It’s the multiple follow-up surgeries after a mastectomy and the subsequent infections; the radiation that doesn’t always improve survival and the cancer risk that can come with too much of it; the sometimes unnecessary chemotherapy and its life-sapping effects. For some in the field, that collateral damage is getting harder and harder to justify.”1
The overdiagnosis of DCIS as breast cancer is wide spread and causes a considerable amount of harm. Peter Gøtzsche describes it like this: “This result is alarming. Not only because these women will have to live the rest of their lives as cancer patients, fearing that the ‘pseudo-disease’ – which never was a disease and never would have been were it not for screening – would come back and kill them, but also because some women die from the unnecessary treatment. It is a new ethical dilemma in healthcare that some people will have to pay with their lives to enable others to live longer.”2
Like Gøtzsche, Siobhan O’Connor, the author of the TIME article, thinks cancer has a language problem. It’s the war metaphors we use when we refer to the battle against cancer. Richard Nixon declared war against cancer over 40 years ago and others have followed in his footsteps, but it is “a war that drafts soldiers who never signed up for it, who do battle and win, or do battle and lose.”1
In 2015 a diagnosis of breast cancer is not necessarily a death sentence or the beginning of the end. While increasing numbers of women are being diagnosed with breast cancer, the death rate over the past 15 years or so has remained largely the same, mainly due to better treatments that are now available.
Eight years ago Desiree Basila went looking for options when she was diagnosed with DCIS and told that “there was a slot open the following week for a mastectomy.” She made an appointment with another breast surgeon and spent half an hour grilling her. She was still not satisfied when the doctor recommended a lumpectomy. Frustrated she stood up and prepared to leave and then issued a half taunt, “What if I decide to just do nothing?” Only then did the doctor say “Well, some people are electing to do that.”
Basila sat back down and after another half an hour spent discussing other options with Dr Shelley Hwang, she elected to start taking tamoxifen, a drug that blocks oestrogen, and to enrol in a clinical trial involving active surveillance. Basila’s doctor, Dr Hwang, is now chief of breast surgery at Duke University in North Carolina, and Dr Laura Esserman, a surgeon at the University of California, are currently leading a number of studies on women who have been diagnosed with DCIS. Dr Esserman is creating a DCIS registry and launched the WISDOM study which will randomise women with DCIS to either annual screening or a more personalised screening approach.3
In the UK an investigation called LORIS is under way. Loris is a 10-year randomised controlled prospect-ive study, funded by the UK’s national Institute for Health Research, which will include 900 women. Half will get the standard care – surgery, and half will be actively monitored.4
“My personal view is that enough time has been spent arguing about screening, and we now should be addressing the issue through well-run clinical trials that are long overdue,” says Dr Adele Francis, a breast surgeon at University Hospital Birmingham and the lead on the LORIS study.1
The other important people in this dilemma are the women with the diagnosis. “Change in medicine comes from patients,” says Dr Esserman. “My patients don’t like the options we have. So I say, Get the facts. Find someone who will go through those options with you.”
New Zealand women also deserve to be offered more options than surgery.
12 October 2015, TIME Siobhan O’Connor. Why doctors are rethinking breast cancer treatment.
Peter Gøtzsche. Mammography Screening: truth, lies and controversy. Radcliffe Publishing 2012.
Alexa Schirtzinger: Wisdom Study: Discovering the Best Approach to Breast Cancer Screening, Sep 11, 2015
Cancer Research UK: A trial comparing surgery with active monitoring for low risk DCIS (LORIS)